by TOM PAGONIS and KEVIN KUO
The arrival of bioceramic endodontic sealers onto the clinical endodontics playing field is a game changer. The introduction and increased use of these advanced materials continue to fulfill the main objectives of endodontic obturation. Their chemical formulation, physiochemical, and biological properties have altered our concept of obturation from using biologically inactive materials to utilizing biologically active materials. We have therefore moved from a physical endodontic seal of inactive materials to a biological endodontic seal of active materials by way of biomineralization of dentin with bioceramic sealers. Of note, Endoseal MTA (Maruchi, Wonju, Korea), one of the newest and most tested materials, excels with high biocompatibility, excellent antimicrobial properties, excellent flow, expansion during setting, high radiopacity, low solubility in contact with tissue fluids, and most importantly, a substantially shortened setting time in minutes. (1- 4)
The rapid-setting ability of Endoseal MTA creates a completely new repertoire of clinical applications and appointment efficiencies as compared to past MTA and bioceramic sealers that sets slowly over hours. In past generations of MTA/bioceramic sealers, clinical applications beyond obturation were limited due to the risk of the material wash out in scenarios, such as pulp capping, perforation repair, and root end surgery--which would then require a more substantive and more difficult-to-use MTA/bioceramic bulk-putty with additional appointments to confirm setting. On the other hand, Endoseal MTA's patented formulation uses pozzolan reactions to quicken setting times without adding chemical catalysts that disrupt biocompatibility and bioactivity. Its novel pozzolan cement-based formulation also promotes intratubular biomineralization. (5,6)
All-in-all, the potential of this material goes well beyond nonsurgical root canal treatment and makes it a “go to” or multiple use material – it is the “Swiss Army Knife” of bioceramic sealer materials. Let us take a closer look…
Multiple uses of novel Endoseal MTA Bioceramic Technology
I. Nonsurgical Considerations
The primary objective of this biologically-based treatment consideration is to physiologically induce both apical closure and root development. In addition, pulpal regeneration procedures can repair damaged tooth and root structures. Endoseal MTA, with its favorable handling characteristics and shortened setting time, make it an excellent choice for regeneration procedures. Intracanal application of approximately 3 to 4 mm of Endoseal MTA adjacent to the newly formed apical clot or collagen plug is one of the final steps of this clinical procedure.
The fluidity of Endoseal MTA is perfect for regenerative endodontic procedures as it can flow into the blood clot or collagen barrier. It is difficult to properly compact MTA or bioceramic putty into such large immature canal spaces, which require a balance of enough compaction and too much compaction thereby pushing the bulk material into the apex. Excessive material into the canal will disrupt regenerative healing and basically initiate apexification instead.
This represents a more traditional clinical approach of managing the immature apex of a pulpally necrotic tooth. Apexification treatment includes either the intracanal administration of a biologically appropriate material or the administration of calcium hydroxide, whose mechanism of action is to provide an antibacterial environment whereby a calcific apical barrier is created. The Endoseal MTA apexification requires only one appointment and its novel and proprietary material addition of pozzolanic materials, such as amorphous silicon oxide, promotes increased calcium silicate hydrate thereby contributing to material durability.
In other words, after properly placing an apical matrix in an apexification procedure, such as a collagen plug, one can back-fill the entire immature canal with Endoseal MTA without the tedious mixing and condensing of MTA or bioceramic putty.
There are several clinical conditions that require nonsurgical repair including communication between the pulp space and external root structure by way of root resorption defects or iatrogenic perforation during instrumentation or post space preparation.
Endoseal MTA is an excellent material choice for small perforation repairs as it effectively seals and promotes healing of periodontal structures.
II. Vital Pulp Therapy
This treatment also addresses the immature apex of a permanent tooth but it involves leveraging the physiological capability of vital pulp tissue towards continued development of the root apex and root formation. The apexogenesis procedure involves partial removal of affected pulp and direct application of Endoseal MTA. After careful evaluation of treatment considerations and under certain conditions, this procedure may be indicated for mechanical or carious exposure of the pulp.
Endoseal MTA works well in apexogenesis as one can easily place a drop of the fluid material over the exposure without worrying about packing MTA or bioceramic putty into the pulpal tissue, causing inflammation and pulpitis. The rapid setting time then allows for immediate permanent restoration.
Primary Teeth Indirect Pulp Capping
This treatment is also intended for deep caries that approximate the pulp of a deciduous tooth. Performed on pulpally asymptomatic primary teeth, this procedure contemplates intentionally leaving caries immediately adjacent to the pulp (rather than exposing the pulp) and applying a layer of Endoseal MTA followed by a restorative material. Interestingly enough, the literature suggests that future pulpal reentry is not necessary (7,8) and that long term success is good if not higher than pulpotomy. (9,10)
Endoseal MTA is a great replacement to calcium hydroxide. There is no mixing needed. And it creates a better dentine bridge over the pulpal tissue with less inflammation. The fast setting time and ease-of-use are also great reasons to use Endoseal MTA in pediatric patients, whose patience in the chair can be limited.
Dental Trauma - Crown Fracture with Pulp Exposure
In the case of a traumatic dental injury of an immature vital tooth, a shallow pulpotomy followed by the direct application of Endoseal MTA on the pulp will maintain continued pulp vitality of the remaining radicular pulp in order to promote both apical closure and continued root development. This clinical application works similarly as caries or mechanical pulp exposures.
III. Surgical Endodontics
Surgical Retrograde/Root End Filling
The excellent handling characteristics with its shortened setting time make Endoseal MTA the material of choice for a root end fill following root end preparation. For optimal results, the clinician should consider the combined use of Endocem as the last layer over Endoseal MTA retrofill.
Surgical Root Repair
Endoseal MTA is also an excellent material when considering a surgical approach to repair resorptive small defects or perforations. As previously discussed, Endoseal MTA is highly biocompatible with both excellent handling characteristics and long term material durability.
Overall, in addition to the user-friendliness of its fluidity, the fast setting time of Endoseal will also allow one to immediately restore at the same appointment without the need to place a wet cotton pellet and reappointing the patient to confirm setting.
First coined “Swiss Army Knife” by U.S. soldiers after World War I, this well-known and well-recognized pocket knife with multiple tool applications has endured the test of time and its name alone symbolizes the flexibility and multiple use potential of any device or material. In the new age of bioceramic sealers, Endoseal MTA is an excellent material with multiple applications in clinical endodontics – it is the “Swiss Army Knife” of bioceramic sealer materials.
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